Dealing with Neuropathic Pain

My husband has peripheral neuropathy from cisplatin. What medications are recommended to treat this pain? It keeps him up at night. Are there specialists for this type of pain?

Erin McMenamin, MSN, CRNP, AOCN, Pain Medicine Nurse Practitioner and Program Manager at the Abramson Cancer Center of the University of Pennsylvania, responds:

Neuropathic pain frequently requires treatment with a number of pharmacological agents. Patients generally require some neuroactive agent to treat the electric-like or burning sensation caused by ectopic impulses that are transmitted along the nerve fiber. Common neuroactive agents include anticonvulsants such as gabapentin (Neurontin) or pregabalin (Lyrica); or tricyclic antidepressants such as amitriptylline (Elavil) or nortriptyline (Pamelor). The choice between these medications is practitioner- dependent, since both demonstrate activity in neuropathic pain.

Gabapentin is generally used in a three times/day dosing schedule. Titration is variable, but may start at 100-300mg/day, and titrate as high as 2,700 or 3,600 mg/day if the patient continues to get increasing benefit without side effects. Older patients and those with renal issues generally require slower titration and lower doses. Pregabalin is a medication that is a metabolite of gabapentin, and is also titrated to a three times/day schedule. Maximum dose of pregabalin is 300-600mg. Pharmacokinetics may be more stable than gabapentin, and many patients unable to tolerate gabapentin have success with pregabalin. Many insurance companies require that patients "fail" gabapentin prior to approving pregabalin.

Many patients also require some opioid (frequently called narcotics) to treat their pain. Often these medications potentiate the effects of the neuroactive agents.